The Future of Mental Health

The field of mental health encompasses many different professions. It is good for the public as well as teachers and psychologists in training to know the lay of the land, and to understand current practices in the field of psychiatry, because many referrals are made to this profession. The New York Times recently reported the story of one psychiatrist whose practice has changed from regular talk therapy to to short 15-minute medication adjustment sessions that occur much less frequently. This particular doctor explains in the article why he believes the kind of practice he conducts is now necessary because of the way psychiatrists are reimbursed for their services, and he refers patients who need more traditional talk therapy to psychologists, social workers, and mental health counselors:

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: 'Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.'

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. 'I had to train myself not to get too interested in their problems,' he said, 'and not to get sidetracked trying to be a semi-therapist.'

If you read the entire article, you will learn how this doctor has instituted different efficiency-based business techniques that are a virtual script to get patients in and out of the office itself in the shortest possible time. He explains that this is necessary for him to keep the kind of lifestyle he was accustomed to before the insurance industry made sweeping changes in the 1990s and 2000s in the manner in which physicians are reimbursed by insurance companies. These, he explained, forced him to change the manner in which he practices medicine. There are many thoughtful comments in the ensuing blog discussion. One may wonder if this doctor is making necessary changes to keep up with the times, or question, as Evander Lomke, Executive Director of the American Mental Health Foundation does, whether or not "money is in, and sadly help (not among all, but among too many in the field experiencing the inevitable pressures of time and money) is out."

And do church teachings and opinions on social justice—recently discussed back and forth on America as they apply to public sector workers such teachers, police, and fire fighters (who may earn in "rough figure" ranges, with benefits, between $60,000 and $130,000)—apply to specialists in a field such as psychiatry where salaries are commonly in the $150,000-200,000 range? Some doctors are even wondering if they should consider establishing labor unions for physicians, not only for salary protection, but to allow them professional freedom so they—instead of management by insurance companies—may continue to set and practice standards based on their professional training, competence and guidelines.

Comments

Lauren Orichio | 4/16/2011 - 5:20pm

Your article is written on a topic that has actually had me thinking for a while now. I recently saw a documentary on big pharmaceutical companies, and how their business ventures affect much more than we think in healthcare in America. I am intrigued by the idea that drug companies can target a certain demographic or type of person in America, market some symptoms, and advertise potentially harmful drugs to doctors in a way to make a profit without due consideration of the risks involved for the patients they are prescribed to. This is immediately what I thought of when reading about the psychiatrist who treats solely on medication adjustments in shallow 15 minute sessions with each patient. I feel as though with the overshadowing of drugs and medications as quick fixes in America we have lost sight of simple things we could do to improve our lives that would work just as well as taking any drug. Simple adjustments such as “talk therapy,” exercise, or changing our diets could be all that we need sometimes, but simple adjustments are certainly not what sell.

Several of the postings above alluded to the ethical issues surrounding the transition in practice methodology within the field of psychiatry. As such, I though I would continue this ethical discussion.

After reading the article Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy, it is easy to understand why so many psychiatrists have opted to eliminate talk therapy and rely solely on prescription treatment. But is it ethical to ignore or disregard a client’s personal issues for monetary benefit? What effect does this impersonal interaction have on the client?

Personally, I believe that this shift in practice is undermining the values of the field. These psychiatrists are no longer actively seeking to safeguard client welfare to their full extent, as financial factors are clouding personal efforts. Instead, the psychiatrists mentioned are looking to shortcuts for personal gain. We must be sure that the best services possible are being provided to those in need.

Providing proper services means maintaining competence. The New York Times article mentioned that many psychiatrists fail to get additional training due to fee cuts so as to maintain adequate income levels. If a psychiatrist is not competent in his or her field, how can appropriate up-to-date assistance be provided? This lack in competence would not lend to appropriate professional behavior.

It is my hope that these important issues are addressed, so that we can ultimately assist the client in the best way possible. Establishing labor unions may help; however, the current lack of altruistic behavior in the psychiatric field left an unfavorable impression on me in terms of its future.

On a personal note, I believe that in the field of mental health, medication and counseling should be a combined effort. The profession is meant to help people, not just hand out prescription adjustments. Hopefully, the practitioner's concern for their pocket will not prevail in the end and outweigh their ability to help clients.

When I think of a “psychiatrist”, I can’t help but refer back to the Hollywood scene of a well dressed, soft-spoken, middle-aged woman, talking with her patients as they lay on a squishy couch. Up until recently, I couldn’t even remember the difference between a Psychiatrist and a Psychologist. According to WebMD however, “The short answer is, psychiatrists are medical doctors and psychologists are not. The suffix "-iatry" means "medical treatment," and "-logy" means "science" or "theory." So psychiatry is the medical treatment of the psyche, and psychology is the science of the psyche”. After grasping this definition, it greatly concerns me that medical doctors who are being paid $150,000 – 200,000 a year are seeing their patients for only 15 minute sessions, often months apart. This shows that the medical field is focusing on funds and cutbacks, rather than the true well being of the patients that need help. The only way that this can be resolved is to find passionate professionals who view their patients as challenges who they can help, rather than simply clients, and that insurance companies will not get in the way of this goal. It's truly sad to see that a profession once based off helping those with mental health issues has turned into just another method for picking pockets.

I found the America article titled, The Future of Mental Health to be very interesting. I always thought that a psychiatrist was basically a psychologist who was able to prescribe medication. However, I realized I was wrong when my sister began seeing both a psychiatrist and psychologist. She has her psychiatrist who she only goes to twice a year just to make sure everything is right. However, she sees her psychologist whenever she wants to as many times a year. I feel like it is much more important for the doctor who prescribes the medication to know the patient on a more personnel level and have a closer relationship. Medication is not something to fool around with and if the psychiatrist really got to know the patient on a personnel level every few weeks they could see just how much they improve or worsen. My sister was actually put on a few different medications because the first ones were not successful. Maybe this is due to the fact that the psychiatrist did not know her condition well enough to properly medicate her. Luckily everything is great now but it scares me because I feel as if the doctors are being greedy and selfish and ultimately putting their patients health at risk. I think this issue also goes back to the fact that Americans now a day’s rely so much on medication. Dr. Levine now sees patients for 15 minute intervals to give them medication to fix them instead of listening to their problems and letting them vent. I agree with Sabrina Scanga that a lot of it just comes down to money to succeed in our competitive and stressful society. It is sad that insurance companies are restricting doctors to do their job in order to make more money. It’s interesting, doctors are working less to make more money when it’s usually the opposite and a person needs to work harder to earn more money.

I also wanted to add that I actually wrote about that article from The New York Times in my ethics class. I think that there are some ethical issues that are raised in the situation in that article. I think it can be unethical for the psychiatrists to provide brief consultations instead of longer talk therapy sessions because I think it can harm the patients. It could harm the patients because they could feel rushed and feel like the psychiatrist is not really interested in helping them. It could also harm the patients because maybe the psychiatrist will not accurately diagnose them since they have to do it in a little amount of time. Also, I think it can be unethical because psychiatrists do not want to have a lower income and it can prevent them from doing a good job. The psychiatrists know that they need to spend more time with their patients, but do not because of money issues. They shouldn’t take their personal issue out on the patients. I think it is unethical for psychiatrists to do shorter sessions just so they can make more money.

That article from The New York Times sounded interesting, so I read the entire article. I was kind of surprised at how many psychiatrists do short sessions rather than longer ones to benefit themselves. Psychologists and psychiatrists are supposed to help people and are not supposed to be selfish. The reason people should go into those fields is because they love to help people. I understand that people want to make a lot of money, but I don’t think they should take their money issue out on their patients (by seeing them for less time). It is not fair to the patients. Many people now are so concerned with money and forget what their job is really about. I was really surprised at some of the things that Dr. Levin said in the article. For example, he said: “‘You have to have a diagnosis to get paid’…‘I play the game’” (Harris, 2011, p.4). I was also surprised by this: ‘He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years”’ (Harris, 2011, p.2). I think that is really selfish of him. I don’t think he should be a psychiatrist then, if he is not willing to be paid less to help people. Also, I feel like psychiatrists can not really diagnose people accurately in just a short amount time and the quality of treatment won’t be as good. In the article, even Dr. Levin says that the quality of the treatments he gives now is not as good as it used to be. Back then, Dr. Levin made a diagnosis after he saw a patient about 10 times, but now he does it in the first 45 minutes. I can understand having a 15 minute session with some people who are doing well on their medication, but some people might need more time. Some people may be fine with short sessions if they just need to get a proscription for a refill of their medication.

It is sad how in today’s society everything is rushed around money. Fifteen minuet psychiatric sessions does not seem like nearly enough time to determine the correct dosage of psychoactive drugs. As a patient I would definitely be unhappy and I would feel more like a car on a assembly line rather than a human being patient. However the doctors are not all to blame for the change in short visits. I feel bad that insurance agencies and money restrictions force doctors stop treating patients to the best of their ability. If it were I in the doctor’s situation, I would find it hard to not become more interested in a person’s problems knowing I was on a time schedule. On the other hand maybe the long talking sessions are not necessary for all people. A minister or a well-trusted friend, who is a good listener, may be all some people need! I think that as a society, we have to stop rushing and take the time to listen to each other more carefully and caringly because maybe then people wouldn’t need to pay professionals as much to listen for them.

As I stated in my previous comment this comes as a big surprise to me. The purpose of a psychiatric is to help people get better and while medications can help people, at least I believe so, but that is only one of the aspects that will help a person. I know people who have been to therapy and the most important thing was not the medication but instead the talk therapy that they had. You need to be able to get to know your patients in an order to even be able to prescribe the medication. How would you know in the 15 minutes you spend with a person which medications to put them on, if the medications are working, or if they even need medication? We have come so far in the Psychology field and now it see ms we are taking a step back. As a society we need to step up and voice our opinions about this in order for it to change.

I for one have never been interested in the life of a psychiatrist since I am not a huge fan of prescribing drugs to people who do not need them. I do believe that there are many mental health issues that require drugs to help limit the effects on the person but, when I’m treating 1,200 patients I can safely make the assumption that at least half of those people’s issues can be cured by talk therapy.To my surprise as I attempt to become a clinical psychologist in the future I am told over and over that as a psychologist I will have to deal with mental health issues faster due to the insurance company pressure. This is incredibly disappointing to me because I don’t believe people around the country are receiving quality care. I’m just scared the system will get worse as time goes on and it will be expected of psychologists to cure patients within one or two treatments.Because of this knowledge I am going to attempt to go into the field of sports psychology and combine the two things I love most. In this field I will be able to get the time I need with the athletes and help them with their own issues while making them mentally tough. This is a field where I feel like I can make the most impact on people who can use my knowledge in mental processes to their advantage and I can only hope of having the opportunity to get a job in that field.

After reading this article I couldn’t help but feel a little frustrated and somewhat appalled. In comment #14 Shayne Labudda makes an excellent point. Does the pharmaseutical industry really have our best interests in mind or are they making insurance and drugs as it is just for a big money scam? With psychiatrists having this impersonal relationship with their patients they cannot truly know if they need medication or even how much because they barely know anything about them or their problems. To me, in many cases not all, medication is just a quick fix for the patient and dollar signs for the drug companies and the psychiatrists. If people are made to think they “need” this medicine they are going to continue to use it for years and maybe even for their entire lives. I could just imagine how much drug companies are making on all of these refills. Of course there are cases where medication is necessary but when this is determined it is usually after numerous visits to a therapist and after other strategies have been attempted.

A comment that the psychiatrist quoted in the article made that aggravated me was in regards to “keeping his standard of living”. Both from the information in the article and previous experiences with psychiatrist, they are pretty well off. It is hard for me to believe that the change in the insurance was so much that he wouldn’t be able to live a comfortable lifestyle. Of course you go to school for certain things because it has good pay but you should also, as he mentioned he did, want to help people and have a positive effect. Unless it is just all about the money, psychiatrist should make the small sacrifice of down grading from their Lexus to an Accord in order to make a better difference in their patients’ lives.

This article was slightly disturbing to read because I always thought that the most important thing for a doctor, therapist, or any type of professions is to help the patients in anyway they can. These cuts are making it hard for these professionals to help their patients. Regardless of if an insurance company is providing assisting the person, I think that it is important for a customer to get all the help that they want or need. Someone with a serious issue cant just be rejected or ignored because insurance doesn’t cover the help they need. I think that there should be a happy medium so that patients get the help they need with having some kind of insurance to help out.

Although the method of giving "short 15-minute medication adjustment sessions" may seem beneficial for patients at this current moment, further complications or problems could arise in the future because of the lack of communication and general concern of the psychiatrist. As of now, we don't fully know the extent to which many of these medications may help or harm us, since many seem to be newly developed or recently changed. In addition, some of these patients who are given this medication may not in all actuality need it; they may need the comfort of a psychiatrist to listen and give advice. The psychiatrists of today who are involved in this "quick fix" type of solution are fixing the problem for now, but personally, I feel they are being lazy and almost selfish. They are not concerned about the possible future outcomes of this method of psychiatry, however are more interested in the monetary benefits for themselves. At a certain point in my life, I had personally heard of a story in which a patient had been recommended medication for depression problems. This person whom I spoke to felt quite insulted and shedid not feel they were getting the necessary help. Rather, she felt an overwhelming pressure to take medication that she were not comfortable taking, in order to improve a minor, short-term problems. In cases such as these, patients are solely looking for some sort of advice or support from psychiatrists, however it seems to be difficult to find. I personally find the idea behind this article to be disturbing. The future of mental health, which affects many people and multiple professions, seems to at this point be quite scary and questionable.

This comment is for Bill deHass' posting number 4. Yes, I agree that many medical doctors are putting their patients on anti-depressant/anxiety medication. I worry sometimes about the kickbacks for promoting medications and wonder how much of a doctor's stock portfolio contains the drugs they are more likely to prescribe. It is nerve-wracking to me how much people are just medicated without being analyzed to determine if the issues can be treated by simple discussions and changing negative aspects of their lives.

I think people have more ability to control their mood than being given credit, but unfortunately this is an instant gratification type of world now a day, and the quick fix is to drug people. Simple things such as exercise, a good diet and quitting habits like smoking and drinking can physically change a person, which results in a change in mood. People prefer to be lazy and the doctors don't seem interested in giving the tough love dose of telling patients to basically work on their selves, and stop blaming the world for their problems.

This article discusses how psychiatrists these days are simply seeing their patients for short, 15-minute sessions in which they make a quick diagnosis to prescribe medication to their patients. I personally found this very shocking because I had always been under the impression that psychiatrists spent many hours and many sessions getting to know their patients and their issues before prescribing them medication. I simply do not understand how a psychiatrist can make an assumption on what is best for their patient in that short of a time. This leads me to believe that the patients are not receiving the proper medication. How can the psychiatrist know right off the bat that a certain prescription is best for a certain patient after only spending 15 minutes with them? All patients are different and have unique problems. I feel that it is not fair for a patient to spend so much money on a psychiatrist only to be rushed in and out of their office and possibly with a prescription that will not even help.

At first skim of “The Future of Mental Health Response” I saw 15- minute medication adjustment sessions and was confused. I continued to read, focusing on the details and learned about what the session referred to. It took about two to three months for my psychiatrist to ask me how I felt about the possibility of taking medication, let alone him prescribing it on the spot. With the side effects that can possibly accompany the drugs, it was reassurance that I was not just some patient. My psychiatrist actually took the time to get to know me well enough to recognize there was something wrong and that I should be given something. I find it unethical and borderline negligent of this psychiatrist to have the audacity to claim he properly diagnoses his patients and provide them with prescriptions. If I were his patient and every session were only 15-minutes I would feel that I had been cheated out of my money. How has this psychiatrist been able to conduct his practice without encountering any complaints or legal incidents? I find it irresponsible and foolish of these patients to trust him, regardless of where he received his degree from, with providing a diagnosis and possibly drugs in such a short amount of time. Further I was repulsed when I read the doctor “has instituted different efficiency-based business techniques that are a virtual script to get patients in and out of the office itself in the shortest possible time.” Where is his integrity? Parents tell their children to grow up and become a doctor for the respect that comes with the title. Maybe parents tell their children to pursue that profession so they can help people as opposed to “sweetie, you should become doctor for financial stability.” It really does not sound as appealing to a child.

Although I do not agree with the practice of this particular psychiatrist, and apparently many others like him, I can completely understand why they would change the way that they practice medicine. When these people went to school and decided to become psychiatrists they were doing so with the idea that they would be able to live a certain lifestyle along with their profession. Now that times are changing, economically especially, some people feel that they need to do whatever is necessary to maintain their lifestyle. These psychiatrists are not leaving their patients in desperate need of a talk-therapy session; it says in the article that patients who need more therapy time are referred to a therapist for further counseling.I am not advocating this behavior but, I think that it is important to look at both sides of the situation. The psychiatrists are not abandoning their patients; they are still meeting with them (of course, for much shorter amounts of time) and prescribing medicine that they feel is appropriate for the situation. It may be helpful for the psychiatrist and therapist to discuss patients and medications that they are taking. Although this would be ideal, I don’t know if psychiatrists would be willing to do something like this seeing as they are cutting down appointment time with patients.

This article discusses how psychiatrists these days are simply seeing their patients for short, 15-minute sessions in which they make a quick diagnosis to prescribe medication to their patients. I personally found this very shocking because I had always been under the impression that psychiatrists spent many hours and many sessions getting to know their patients and their issues before prescribing them medication. I simply do not understand how a psychiatrist can make an assumption on what is best for their patient in that short of a time. This leads me to believe that the patients are not receiving the proper medication. How can the psychiatrist know right off the bat that a certain prescription is best for a certain patient after only spending 15 minutes with them? All patients are different and have unique problems. I feel that it is not fair for a patient to spend so much money on a psychiatrist only to be rushed in and out of their office and possibly with a prescription that will not even help.

After reading this article I learned how much the mental health industry has changed recently. Psychiatrists have become more concerned with giving out medications to their patients instead of listening to their problems and solving them. This change has been due to the alternating ways of the insurance companies that demand psychiatrists to see more patients at a faster rate in order to keep their income steady.I feel that this is detrimental to the health of people because their issues are not being dealt with properly. Instead of dealing with health concerns in the safest way, psychiatrists are taking the easy road by prescribing medicine without knowing all of the details of their patients. Due to this issue, I think it is a good idea for doctors to begin labor unions in order to keep the practice thinking in the proper way. In doing this, insurance companies will not be leading the medical industry, which can keep the patients safe and healthy.It is extremely scary to see how corrupted industries have become, which cannot be good for the health of the patients who need their mental health issues solved. It is hard to believe that the industry has been changing due to money issues instead of individual needs. If individuals are being prescribed prescriptions more easily, more issues may be created for that particular individual. Hopefully labor unions can be formed in order to keep the health of patients the first priority in the mental health industry.

I found this article extremely interesting and mind- provoking. As a side note to the article, I think that many people have a misconception of a psychiatrist. I feel that it is easy for people to misunderstand and confuse a psychologists and psychiatrists. Back on topic, it’s interesting to read about the changes that have occurred from Dr. Levin’s viewpoint because of the changes in insurance companies. It is also upsetting to read how his passion to help others has turned into a passion to fill prescriptions. I, like Evander Lomke, questioned “money is in and help is out?”

Reading this blog, as well as the comments, definitely opened my eyes to both ideas and facts that I had never realized before. What started out as extensive talk therapy by psychiatrists to patients has now turned into extremely brief meetings where a prescription is given out. The fact that patients are now no longer encouraged to talk out their problems really saddens me. Not only are talk sessions unavailable for patients, they are actually discouraged by psychiatrists. Being denied the opportunity to talk to a person that was once available to share your problems with can be really discouraging to a patient. Although medication can undoubtedly help people, having someone to receive advice from and share your feelings with often makes more of a difference. The fact that psychiatrists can give out a prescription for medication without really talking to a patient is also an alarming fact. If a psychiatrist does not know their patient on a personal level, how can they be able to know what type of medication is necessary for them? I believe that a psychiatrist should know their patient on a personal level, including the state of mind they are in and their current situation, in order to be able to suggest a specific medication. Specific medications could have damaging effects on a certain kind of person, which makes the situation that much scarier.

Thank you for posting this article because it really gave great insight into an issue that many are unaware of. I am saddened by this article because it shows how much insurance companies and monetary restrictions play in the role of professions such as psychiatry. I believe that talk therapy is a very importance component that patients expect and deserve in their sessions. They deserve alternative options to medication because we are all aware that medication does not simply solve every issue. Sometimes, medication may make things even worse. Also, I know that I would like to have a personal relationship with my psychiatrist and not feel like I was being rushed out of the office with a prescription in my hand. This article shows that psychiatrists do have the best interests of their patients in mind yet they are restricted to show those best interests by the restrictions set by the insurance companies.

I think that it is a great idea for physicians to create a labor union for themselves to protect their rights and the rights of their patients. While doing some research, I came across the Union of American Physicians and Dentists. This union aims at protecting physicians and giving them the tools necessary to take control of their own patients and practices. It aims at eliminating problems such as the ones stated in the article and I believe that this is a fantastic option and one that should be taken into account to rid of these saddening situations.

The insurance industry has changed the way that psychiatrists function, relying more now on just medication checks, rather than actually helping their patients with talk therapy. I think that this has made psychiatrists seem less human and more robot like in their profession. They are now just puppets to the insurance industry. I guess though in this void, other professionals such as psychologists and social workers are picking up the business of doing talk therapy and so this is enhancing their careers.

I think that the psychiatrists would feel that this is not as worthwhile because they will not get to really know their patients as they did in the past. They will not get to actually help their patients by talking with them about their struggles and imperfections. We now will be relying on the psychologists, social workers and therapists to fill this gap. The future of mental health is now in the hands of other professionals and not the psychiatrists, except for medication adjustment.

The main difference between psychiatry and psychology (excluding salary) is the fact that one prescribes medication and the other does not. A psychiatrist deals with patients who have mental illnesses and need medication in order to treat different problems. The article above reflects the idea that a particular psychiatrist needs to shorten his sessions to 15 minutes with patients due to Medicare and Insurance Policies. From the psychiatrists perspective, he may have to change his way of practice because the amount of money insurance companies provide it too little to keep his practice running smoothly. Yet, on the other hand we think of the patient’s ability to succeed in a session. This particular psychiatrist has many years under his belt, which probably makes diagnosing patients much easier since he is familiar with the field. However, what about new psychiatrists in the field who are trying to diagnose patients in such a short amount of time with little experience? These new and rising professionals will probably be struggling in starting up their practices and also have to deal with the demanding policies enforced by insurance companies. A new psychiatrist may find it difficult to understand the severity of some mental illnesses presented by their patient in a 15 minute session.In turn, these struggles may alter the type of medication and treatment the patient will receive. If a psychiatrist is unable to provide quality services to their patient due to implementing facts presented from insurance companies, they can be viewed as acting in an unethical manner. One of the largest ethical codes it to provide the best environment and treatment for all patients to fulfill a greater well-being for all parties involved. How are these services going to be fully provided if the psychiatrist does not even know the clients name? The biggest issue in the situation above is the insurance companies. Once their policies are altered, I believe treatment may be improved. However, at the same time, psychiatrists should not solely focus on the amount of money made from a session, but the amount of help and success the client receives.After reviewing the article, Troubled Children: Diagnosing, Treating, and Attending to Context (http://z3950.muse.jhu.edu.online.library.marist.edu/journals/hastings_center_report/v041/41.2.parens.html, it brings up some interesting points pertaining the process psychiatrists go through when diagnosing a client. Although the DSM plays a large part in the diagnosis of a patient, a psychiatrists needs to also take into consideration the clients culture, environments and race to name a few. The psychiatrists make a few judgments before prescribing any medication. For this reason, if a psychiatrist only meets with a new patient for 15 minutes and is diagnosing the new patient based on the DSM and judgments, how accurate will his results be? The authors stated the following when introducing the judgment process, “more and more children in the United States receive psychiatric diagnoses and psychotropic medications—this is not news. With those increased rates of diagnosis and pharmacological treatment come sometimes intense debates about whether those increases are appropriate, or whether healthy children are being mislabeled as sick and inappropriately given medications to alter their moods and behaviors.” The fact that more children are being put on medication may be correlated with the decrease in time in sessions.

I think it is extremely unfortunate tha tbecause of how much insurance will pay, Dr. Levin couldn't listen to one of his patients who was looking for help. When he opened his own private practice, Dr. Levin was meeting with less patients but for a longer period of time and more often so he was capable of getting to know them on a personal level. As stated, "he knew his patients' inner lives better than his wife's; now he often cannot remember their names." People chose their profession for a reason, hopefully many for the love of what they do. However, I certainly believe the statement, "money is in and help is out" due to economic hardships. People are doing what they need to do based on how much money they will be making. However, I find it difficult to do a job all day, everyday if you do not enjoy it. It would be difficult for people to put all their efforts into a particular task if they do not want to be there. Dr. Levin seems as though he truly enjoyed his patients company, listening to their needs and providing advice. It is disappointing Dr. Levin stuck with his new practice of 15 minute medication adjustment instead of regular talk therapy since that is what he orginally loved to do.

After reading this article I was both confused and horrified by what I had read. It is sad that the shift it today’s society has caused the main concern to be for time and cost efficiency rather than patient’s well-being. But isn’t there a way to achieve both? Is it possible to reduce the amount of time and care given without reducing the quality? Quickly prescribing a patient with medication and getting them out the door quickly may work for the short-term, but probably will not work as a lasting solution. Spending the extra time in talk-therapy may be what the patient needs. Medication alone may not be the solution a combination of talk therapy and insight from a professional in mixed with medication may be what is necessary. In today’s economy it is difficult to leave money out of anything since it is clearly a consideration in almost anything. But hurrying a patient through the system with no concern for their well-being will not end up any more cost efficient. The patient will keep returning, unhappy if they are not treated properly. As someone mentioned in the comments patients could have a bad reaction to the medication if not properly monitored which could have serious consequences for the patient.

This article was definitely a very interesting one and I have a lot of opinions to contribute. I feel that psychiatrists and therapists are there to help their patients, in any which way possible. Psychiatrists have the power to prescribe medications, but I feel that medications aren’t the “only way out” in order to help a patient get better. Believe it or not, I feel that talk therapy and real life communicating between a therapist and patient is the key to succeeding within the therapeutic sessions. When too many medications are prescribed, a patient can easily get addicted, and the purpose of the medication is thrown out the window, as well as any help that may have ‘worked’ up until that point. Dr. Levin was once a psychiatrist who sat down and had long therapy talk sessions with his patients, and could deal with them on a name to name basis, and enjoy their company as he learned a lot about their individual lives. He was there to be a good friend and a good advice giver, which I feel is extremely detrimental in the field of therapy. Now a days, he has become a psychiatrist that prescribes medication to his patients all day long within short 15 minute sessions. I feel that 15 minutes is not enough to learn all about a person’s life and serious issues and problems and a drug should not be prescribed to a patient unless it is clear what conditions exist or may not even exist. The worst thing in the world would be to issue a patient medication because they may be “depressed”, meanwhile in reality they just need a good friend or listener to hear out their daily hassles. A therapist or even psychiatrist is a person that should know you, learn new things about you, and be on a name to name basis with you because they have a lot of power to help a patient get well, whether it may be through life talks or issuing prescription drugs to those who are in desperate need of help.

As many others have stated, I previously thought that the only real distinction between a psychologist and a psychiatrist was the ability to prescribe medication. The fact that there is a shift in psychiatry away from therapy and truly getting to know clients is a little unsettling. Mental disorders and emotional difficulties are complex issues, so I find it doubtful that even the most experienced psychiatrists can make an accurate and complete diagnosis is such a short time. I think these appointments probably provide some benefits for the clients, but I know personally I would rather feel that my doctor really knew me and my problem. I do understand that time is money and we all want to live comfortable lives and have bills to pay, but in a field like psychiatry where your primary role is to help your clients, it would be nice to know that most professionals want to truly help, not just make money. An interesting article from a practicing psychiatrist in Australia about the difference between providing efficient service and making money: "Only martyrs need apply: why people should avoid isolated psychiatry." The author argues that his own practice is not the norm and that most private practices have difficulty surviving. Being that this article is from 2003, it would be interesting to see how widespread the shift that Dr. Levin sees occurring is. Perhaps in the last 8 years there have been significant changes or maybe it is due to the insurance differences between the US and Australia?

This article really surprised me. I do not think it is a good idea that psychiatrists are focusing on medication as a focal treatment. I think it is highly unlikely that a psychiatrist will be able to provide an accurate medication and dosage after talking to a patient for only fifteen minutes. The increased number of patients being seen is ridiculous. A fifteen minute session is not nearly enough, and was significantly reduced from the length of a session held before the cut backs. It can be assumed that with the shortened meeting times, the quality of helpfulness has decreased. Maybe physicians will just start “yesing” patients, or start making up diagnoses to get the patient out of the office faster, and make time for even more appointments in one day.

Money is not everything. Quality is still valued and important, but that sometimes escapes peoples thoughts.

I think it is a good idea to establish a labor union for physicians. The teacher’s union seems to be working in protecting the rights of teachers, so why wouldn’t it work for physicians? The union would create a standard that would apply to all physicians, and all patients would be treated accordingly. I think having a union would prevent or lessen fraud by physicians, and give a better sense of relationship between the patient and physician.

I was definitely surprised by the information in this article. Although I do not know much about psychologist's work, I could never imagine someone having a 15 minute session with his or her patient. I guess it is because I'm so accustomed to heairng friends say that they go for an hour or because television discusses how certain characters go to see someone for an hour session.

I think that Katie and David (71 & 72) brought up interesting points. We do live in a fast paced world, so shouldn't meeting with psychiatrists be just as fast paced? We are so focused on doing so much in one day, so doesn't it make sense to meet with psychiatrists and other professionals quickly in order to be able to accomplish the other 50 tasks we expect to do in one day?

Personally, I think that people need to slow down and take the time to work with a psychiatrist. Prescribing someone medication is something that should not be rushed; psychiatrists need to make sure that they know their patients and are prescribing appropriate amounts of medications for people. There have been way too many issues with people dying from overdosing or mixing medications, and I think that people need to take medications more seriously. Medication is just seen now-a-days as the easy way to cure people; people do not see any risk in prescribing or taking medication.

This article was an interesting one to read and the comments below it equally interesting. Although many have already made some major points clear, I wanted to share exactly my take on this issue. I would have to agree with those who say that this is something they would expect. It's not necessarily justified, but personally, I can see how it has come to this.

The first thing that came to me as I was reading this article was MONEY! In todays world, economic profitability has become this evil yet guiding force. Therefore, because money has such a status, the common good of people has diminished. What is sad is that professionals like psychiatrists are falling into and further digging the hole of diminishing common good.

I can understand why money is such a big deal for Doctors because they do spend alot on their education. Having a sister who is pre-med I know first hand how much money will be spent on the education. However, I am still taken back by Dr. Levin's comment, 'Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.'

Just a final thought that is still lingering in my head is how can a psychiatrist prescribe the right medication if they themselves don't spend time with the patient to learn more about them? How is a teacher to know how a student learns best if they dont spend time to talk to them? This makes me wonder that there may be even greater issues regarding this topic.

During this day and age of there being pill ‘fixes’ for most everything, it sadly doesn’t surprise me that the field of mental health has had a decrease in talk therapy and in increase in prescriptions. Our society has come up with ways to make everything easier and quicker: is psychiatry falling into that category as well? Are people going into therapy looking for a quick fix to their problems instead of a laborious talk therapy? I personally feel that the talk therapy is even more important that the quick fixes. In order for a psychiatrist to know a person and their issues they must speak on multiple occasions. They cannot just speak for 15 minutes to adjust medication. Not only does talk therapy allow the psychiatrist to get to know the patient, it allows the patient to explore their own thoughts and get to know themselves and their issues even better. I think it is sad that because of insurance and money, patients are being prescribed medication without adequate talk therapy prior.

Initially, I found it interesting to learn about scrupulosity. Since I had never heard of this before, I looked up the definition of scrupulosity and found it is a psychological disorder characterized by pathological guilt about moral or religious issues. It was described as a spiritual form of obsessive compulsive disorder. It is understandable why this would be a frustrating condition for therapists and psychiatrists to treat, as how does one go about dealing with a person who is spiritually dead? This is a concept that is new to me.I appreciated the connection between the woman who had been “married five times but had never really been married” and scrupulosity. This woman feels as though she is no good and useless. She believes that everything she does is evil. She thinks that she is incapable of being loved. This leads me to the question: How is it humanly possible for all of these characteristics to lead to a successful marriage? And the answer: It probably is not possible. Clearly this spiritual disorder is affecting other aspects of the woman’s life. Here I begin to see the connection between the fields of psychology and spiritually.A spiritual disorder has the ability to impact not only one’s spiritual life; as the opposite is also true. For this reason, I agree that at times, churches should refer their clergy for psychological therapy instead of turning to the spiritual or sacramental resources. In the same sense, it is equally important to experience spiritual therapy in different instances. Both fields bring diverse points of view and outlooks to the table; both are beneficial in certain circumstances. After researching what exactly spiritual therapy is, it seems as though the two fields obviously overlap. Spiritual therapy helps one gain more understanding and consciousness. According to author Dorothy Becvar, issues of spirituality can be brought into the therapy room; the two fields can work together.

I read your article with sadness and must point out that this article is dealing with a psychiatrist who is in private practice-not a counseling psychologist who works within a college, school, agency for the developmentally disabled, probation system or other court-related facility. So, yes, it is true private practice may be very challenging-difficult.

The other side we haven't explored is that there may be MORE opportunities for guidance counselors, licensed mental health counselors, etc. who work within AGENCIES because they can and will be hired at lower rates that the Ph.D. clinicians or M.D. psychiatrists.

Check out the web site of the American Counseling Association (http://www.counseling.org/)-they are much different than the American Psychological Association (of which you are familiar) and your review of their website-and maybe becoming a student member-may give some other ideas. I think I might be able to put you in touch with someone who has gone on to become a certified counselor in the school systems. We can go over this more. bvo

Dear Dr. Van Ornum,Question: What percentages of psychiatrists still do therapy in addition to counseling? Answer: The overall response rate was 60%. Primary care physicians mostly report awareness of pediatric ADHD guidelines and follow those clinical practice recommendations. But, some physician dissimilarities are seen, and areas for enhancement and improvement are noted. Many primary care physicians show low access to mental health services, low insurance coverage, and other potential system barriers to the delivery of ADHD care. It stated that “Additional study is needed to confirm provider-reported data; to determine what constitutes high-quality, long-term management of this chronic condition; and to confirm how reported practices associate with long-term outcomes for children with ADHD.”http://pediatrics.aappublications.org/cgi/content/abstract/114/1/e23

Since i was a freshman in high school, i set a goal to become a practicing psychologist. After having gone through something in my personal life, i became extremely motivated to help others because others had been of such great assistance to me. After applying to graduate schools for programs in clinical psychology and mental health counseling, and after learning more about the realities of being a counseling psychologist, i have come to the realization that i will not be able to reach my goals of helping others sufficiently; between insurance complications and the spirit of the times, it just doesn't seem realistic anymore. My previous doubts have only been solidified by this article. In one of my classes today, we were talking about how my generation (around the age of 21) is completely focused on instant gratification. We don't want to have to work for things-we want our problems to be solved immediately. For someone who has decided to enter therapy, however, immediate success is impossible. How can we be living in a world where immediate gratification is so consistently necessary, but not always possible? Certain things, including mental health in particular, cannot be achieved in a brief 15 minute session where only medicine is prescribed.it scares me to think that counseling psychology is following the times and finding its way into the realm of instant achievement. When will people realize this just doesn't work?

In high school I was seeing a psychiatrist who was a family friend. She was outstanding. Sessions were always 45 minutes of talking. I was able to really open up and talk through things that were going on in my life. She prescribed me medication and helped me get better and better. We began to have sessions much more spread out and then finally she explained she was retiring. She gave me provided me with a few names in the area to check out for future psychological assistance. I chose one and began to see her. Even my first session with my new psychiatrist was shorter than I'd ever experienced before. She kept me in the room for about 10 minutes (maybe even less) and didn't seem to care about my background or what my anxiety disorder entailed. She was simply focused on what medication to prescribe me and a $225 check. I gave it a second chance about a month later but the same thing happened. Needless to say I was extrememly disappointed and never went back. It is such a shame that therapy has come to this.

Katie (#37), I completely agree with the points you made. I don't understand how spending 15 minutes with a mentally ill individual can provide one with enough information to prescribe them medication that could drastically alter their mind. How can one be sure from these short sessions that a patient isn't lying? Quick fixes usually seem to lead to more problems in the end. Professor Van Ornum (#38), to address some of your questions, I found an article about the differences between psychologists and psychiatrists. The article does touch upon how different types of therapies will work best for different people. Some may benefit from talking through their problems, while others may be more hurt by doing so, making medication another option.Pay close attention to the last paragraph on the first page, which discusses the shift from psychotherapy to medication prescription with psychiatrists. The second paragraph on the second page also discusses the idea of money and fees in regards to therapy. According to the mentioned statistics, psychiatrists would lose a significant amount of money if they were to take part in therapy sessions with their patients then if they were to hold short medication management sessions instead.Another article I found more directly discusses the percentage of psychotherapy occurence with psychiatrists and the rapid decline of these treatments. According to this article, in 2008 psychotherapy was used with less than 30% of patient encounters with psychiatrists.

I'm glad we're all being able to see how part of the real world functions-at least, one practice of a psychiatrist whom (courageously) allowed himself to be questioned by journalists and featured in the NY Times.

How typical is his practice? I am not sure.

Does anyone have statistics about how common this "15 minute practice" is among psychologists?

What percentge of psychiatrists still do therapy in addition to counseling?

Students-can you find any details on google.com, scholar.google.com, or the online data base search engines? bvo

Up until this time, I always thought that psychologists and psychiatrists were one in the same except psychiatrists were allowed to prescribe medications to patients and psychologists were not. I just assumed psychiatrists provided their patients with the same amount of therapy time as psychologists before providing them with an adequate prescription for a problem. I find it a little unsettling that this one psychiatrist in particular only meets with his clients for 15 minutes at a time before writing out some medication. If it were me, I would not feel I knew enough about the client to truly understand his or her position and mental state after such a short period of time and be able to properly diagnose his or her condition. I feel that many times it takes days or weeks or even months to be able to establish a true connection with a client and get a sense of what is going on in that persons life. Sure they could tell you whats going on in 15 minutes, but how would you know they werent lying to you just to get out quickly? Or get a quick fix to a problem when maybe the longer but better route would be to speak to someone about the issue, instead of medicate. Its a tricky situation and a fine line between doing something quick just to get it done and doing something quick because it is correct.

The union idea is an interesting one-it is worked for teachers. I'm surprised that it hasn't brought in much discussion here as it is one of the topics that evokes much thought when applied to the budget situation in Wisconsin, the shirt company fire in NYC, etc. Thanks for mentioning it. I hope others will comment upon it. bvo

Your five points are well-taken. Unfortunately, many mental helath problems (note examples by Janice) go beyond the kind of support that can be given by friends. But many have noted that psychotherapy can serve as a substitute for friendship when people are lonely (i.e. one book was called "Psychotherapy: the Purchase of Friendship") it it doesn't seem fair for employers or taxpayers to subsidize this use of therapy. As you aptly point out, that's what friends are for! bvo

ps I know one person who avoids the proton pump pills by eating small dinners and sleeping up in a chair since the particular manifiestation of acid reflux is coughing. It wouldn't work for everyone and this shouldn't be taken as my giving medical advice to anyone, but it's an example of "rationing" and "frugality" and the amount saved is a car payment.

I believe it is a shame that there is no concern for the individuals well being within society. Physicians should have the personal freedom to do what they would like and it is upsetting and unfair that the focus is on money and efficiency rather then the welfare of individual patients. I feel that simply prescribing patients medicine without listening to their situation and trying to help them will just create more problems for the patient. Hopefully physcians will find a way to create some sort of union that will allow them more freedom to deal with patients in a way that will actually help them rather then just diagnose them for medication.

The article in the NYT and this article and comments are all very interesting to me. I can offer some illustrations of the points that Bill has made from my personal and work experience. In the "olden days" of the 50's and 60's there was a team approach in clinics and hospital settings. A psychiatrist would lead a team of psychologists , social workers and sometimes medical personnel. The social worker's role was to work with the patient's family members. How different things are today! It has been very sad to me to see the changes over the years. My son, who is now 45 was diagnosed with autism and other developmental disabilities at a young age. At age 28 he had his first psychotic breakdown and was diagnosed with schizophrenia. A dually diagnosed individual presents very complicated treatment issues. He has Medicare and Medi-Cal coverage through a huge HMO in CA and received treatment from the same psychiatrist for almost 17 years, which is quite amazing. Siince I am his conservator I've been included in all his sessions and planning. As his doctor gained trust in me we formed a good partnership. He came to rely on me for sending him emails about my son's condition. And with such a long history together, this doctor did learn a lot about my son, even though his primary focus was on medication management. I have a different take on psychotropic meds as my son has been free of psychosis while taking them. He has regular blood tests to check his liver and kidney function, as Bill pointed out meds can possibly do harm to these organs. This particular HMO has a social work department which offers services to family and only short=term counseling. Because schizophrenia is a chronic illness I thought that my son needed someone who would be available on a long=term basis. So,17 years ago, Frank began seeing a Licensed Clinical Social Worker that I had known from my work. This therapist has a brother who is mentally retarded and a bro-in-law who lives with him and has schizophrenia. He really understands the issues! Frank has seen him weekly during crises and otherwise monthly. No insurance covers this. It all comes out of my pocket and I estimate I have spent at least $25,000 over the years. I think the combination of careful drug management and counseling is the best option for my son. Don't we do what we have to do for our children?

One of the most frustrating aspects of my work at Child Protective Services was finding adequate psychiatric and psychological treatment for our abused and neglected children. Many of them were seriously disturbed and needed intensive treatment. We could only use those therapists and doctors on an approved list and these were paid by Medi-Cal (Medicaid) and were not always the most competent. The psychiatrists prescribed meds and followed up with the 15 minute checkups. Some children were on multiple drugs and suffered side effects. Their care was sub-par and yet funding kept getting cut and cut further. The situation in the state is so dire, I can't imagine how bad it must be now for these children and those who really care for them. Bill, you put so well how tragic the suffering is for seriously emotionally disturbed children, their families and their advocates.

The role of the schools since the passage of the Special Ed laws has also been severely curtailed by state and federal budget problems. One facility here may have to close because of cuts in funding. What will happen to the children? How will the parents cope? You wonder if anyone in government cares.

The psychiatrist in the NYT article seemed pretty heartless and his wife, the social worker,even worse. I do think doctors should be fairly compensated and their need for liability insurance taken into account. I know of two psychiatrists who were sued for malpractice. One was in private practice, lost his case and lost his home, savings, everything. The other worked in a psych hospital and won his case after several years of litigation and agony for his family.

I'm wondering what is taught in the psychiatric part of med school. Do they get training in psychotherapy? Or has it been given up on.

Like others have mentioned, I too fear this shift. It's upsetting that so much more emphasis is placed on money than the care and well-being of patients. I know a few people who have sought out therapy in hopes of being helped and instead they were only prescribed medication. In the end, this brought them more problems. I'm starting to wonder if they would have been better off if they tried to solve their problems on their own. It seems strange that psychiatrists are the ones who prescribe the medications to patients, when they are the ones who spend the least time with them.

If people just want drug treatment they'd probably be better off with a psychopharmacologist than a psychiatrist.

This guy sounds like money is what he mostly cares about. Psychiatrists aren't at the mercy of hospitals or insurance companies unless they allow themselves to be so because of wishing to make a certain amount of money. They can work for themselves and make their own decisions about how to treat patients. Having said that, I do blame the greed of insurance companies as well for how this is playing out.

Thanks for writing back and it sounds like you have a Hurculean task. I worked in a private psychiatric hospital in the 80s and could offer many examples of profligate spending of insurance company's money. I also have served as a NYS Disability Examiner for over 1200 cases and have reviewed the work of many M.D.s and Ph.D.s and have a good idea of the kinds of things that milk the system unfairly.

As I mentioned to Michelle, maybe many Americans should be expected to pay out-of-pocket for more medical care-they will be less reckless with their own money. I suspect that the FDA making anti-reflux drugs, allergy drugs, etc. over-the-counter is one way of keeping prescription costs down.

Intersting what you mention about France. Is their tort system like ours? The possibility of nasty malpractice suits puts alot of pressure on doctors as well as pressure to order tests. I'm sure many doctors would glady take a pay cut if these pressures were eliminated.

When doing all the disability exams I was shocked by all the poor people-and children-with Type II Diabetes, Obesity, and Depression. And much of this seemed like it could be prevented.

I do see a Judaeo-Christian theme in this discussion: taking care of the gift God has entrusted with us, or as the nuns used to say, "the temple of the Holy Spirit." I hope to write about this more in the future, as the devil will be in the details as we try to make helathcare avaialable to everyone in the USA. If you have any other ideas you can write me at ornum@earthlink.net. Thanks for stimulating alot of good thoughts. bill